18707 (4) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL.POINT PEN ONLY
BUILDING PROJECT IDENTIFICATION ' - PERMIT NUMBER
haDILDING APPLICATION & PERMIT ' 1 j^(7 �/J
ADDRESS BUILDING -ELECTRICAL-PLUMBING -MECHANICALI' 1 V 1 O'1 '
OWNEITiS PLAN CHECK VALIDATION
NAME "TY. ELECTRIC PERMIT - FEE
PHONE
DUNIACTORS " UTLETS-SWITCHES-RECEP 10.00/1.00
NAME '
LIC.No, LIGHTING FIXTURES 10.00/1.00
DO
ADDADDRESS Rs
RESAPPLIANCES-RESIDENTIAL 4.00
3'
PHONE PANELS 10.00 ' DATE OF APPLICATION _
OR ,PANELS (OVER 200 AMP) ( 20.00 PLAN CHECK FEE P.C.NO,
OP
ENGINEER
LIC No. SIGNS TRANS. 3.00
ARCH.OR END SPECIAL CIRCUIT 5.00 PERMIT VALIDATION
ADDRESS
ZIP TEMP,METER OR POLE INS. 20.00 . U-2
ADAPPLICANTDRESS
'S MOTORS SEE FEE SCH.
SERVICE CHANGE PAJn20.00 '{N X10 IAUC Com (
wO O LICENSED CONTRACTORS D17CLARATION -
a o u I hereby affirm that I am licensed under provisions of Chapter 9 ISSUANCE GATE
(commencing with Section 7000)of Division 3 of the Business and - 9111. ELECT. PLG. MECH.
FN i Professions Code,and my license is in full force and effect. ❑ ❑ ❑
Z o,.,- License Class l.ic.Number - pt� p„� n0
Q w Date Ci YY
Contractor
BUILDING PERMIT
¢ ¢ w a OWNER-BUILDER DECLARATION INFORMATION
a o A D MISC.- REFER TO ORE
w ; y I hereby affirm that I am exempt from the Contractor's License
wOa Law for the following reason.(Sec,7031.5,Businesslnd Professions PERMIT ISSUANCE 10.00 VALUATION. $/FT.
r - Code:Any citycrcounly which requires a permit to construct,alter,
U,
Q 0 improve,demolish,or repair any structure,prior to its issuance,also ELEC.CONTR. LIC.NO. ELEC.
O
n u requires the applicant for such permit to file a signed statement that TOTAL PERIIT TO
w m he is licensed pursuant to the provisions of the Contractor's License
H z i Law(Chapter 9(eommencing with Section 7000)of Division 3 cattle
a Business and Professions Code)or that he is exempt therefrom and QTY. PLUMBING PERMIT FEE V I,
at the basis for the alleged exemption.Any violation of Section 7031.5 STORIES TWE CONSTR.
i by any applicant fora permit subjects the applicant IOU civil penalty gLTER-DRAIN -WATER IEA.) 5.00
of not more than five hundred dollars(5500).1:
5( I,as owner of the properly,or my employees with wages as BACK F LOW PROTECT.DEVICE 4.00 OCc.GROUP RES.UNITS
their sole compensation,will do the work,and the structure is not
intended or offered for sale (Sec. 7044, Business and Professions DRAINS-FLOOR,ROOF,AREA,COND. 5.00
Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work FIXTURES,PER TRAP 5.00 SO,FT,FLOOR AREA TOTAL ACREAGE
r� himself re through his own emred fors provided that such improve-
II ments mselfe not intended or offered prov,however,ided
that such
emprovg GAS-EA.SYSTEM,11NC.40UTLETS 6.00
or improvement is sold within one year of completion,the owner- GAS-EA.SYSTEM-OVER 4 (EA.) 2.00
builder will have the burden of proving that Im did not build or im. BUILDING USE
RES IND CON PB ohne,
prove for purpose of sale.). - INDUSTRIAL WASTE INTER. 30.00
- _ - ❑ I,as owner of the property,am exclusively contracting with ❑ ❑ ❑ ❑ ❑
licensed contractors to construct the project(Sec.7044,Business LAWN SPRINKLERS-1 INC 5 V.B. 6.00 ASSESSORS PARCEL NO.
and Professions Code:The Contractor's License Law does not apply
to an owner of properly who builds or improves thereon.and who LAWN SPRINKLERS-OVER 5 (EA.) 1.00
contracts for such projects with a contractions)licensed pursuunl to SEWER-SANITARY-STORM EA.200fi/10.00
the Contractors License Law. TRACT NO. PARCEL NO.
❑ I am exempt under Sec. ,B.&PC.for this WATER HEATER W/VENT 6.00
reason
Owner P A -$- WATER SYSTEM 5.00
ACC.DATE ACC.FILE NO,
WORK ERS'COMPFNSATION DECLARATION WATER TREATING EQUIP, 5.00
1 hereby affirm that I have a certificate of consent to self-insure, ZONING
or a certificate of Workers'Compensation Insurance,or a emlifieJ ENG.SITE NO.
copy thereof(Sec.3800,Lab.C.).
Policy No. P Company
❑ Certified copy is hereby furnished. FIRE SPRINK ENERGY T-24
Z Z ❑ Certified copy is filed with the city inspection division. MISC.- - REFER TO ORD.
O Applicant Y ❑ N❑ Y ❑ N❑
� N CERTIFICATE OF EXEMPTION FROM WORKERS' PERMIT ISSUANCE 10.00 0 FLOOD ZONE A.L.U.C.
W > COMPENSATION INSURANCI'. PLG.CONTR. LIC.NO. PLG. r rDl.t Y❑ N❑ Y ❑ N❑
CL Z (Phis section need not be,completed if the permit is for one TOTAL l V
hundred dollars 1$100)or less.)
U O 1 certify that in the performance of the work for which this per. OTY. MECHANICAL PERMIT FEE FEE SUMMARY
LL F mit is issued,I shall not employ any person in any mmnncr so as to
U become subject to the Workers'Compensation Laws of California.
G. Date Applicant ALTER OR ADD TO MECH. 5.00 BUILDING
} W NOTICE'1'0 APPLICANT: If,after making this Certificate of Ex-
F Z (minion,YOU should become subject to the Workers'Compensation APPLIANCE 5.00 PLAN CHECK
provisions of the Labor Code, you must forthwith comply with FEE
V such provisions or this permit shall he deemed revoked. AIR HANDLING UNIT(TO 1QOWC.F.M.) 4.00 '
CONSTRUCTION LENDING AGENCY AIR HANDLING UNIT(OVER 1OPWC.F.M.) 6.00 SEISMIC FEE
I hereby affirm that there is a construction lending agency for EXHAUST HOOD (WITH DUCT) 5.00
the performance of the work for which this permit is issued(Sec. MICROFILM
3097,Cie C.). HEATING UNIT(TO 100,000 B.T.U.) 8.00
• Lender's Nome HEATING UN ITIOVER100,000B.T.U.)9.50
- Lender's Address ELECTRIC
Fcertify that I have read this application and state that the above VENTILATION FAN (SINGLE) 4.00
information Is codec[.I agree to comply with all city and country PLUMBING r
ordinances and stale laws relating to building construction, and BOILER- H.P.Dr 100,0008.T.U.) 6.00
hereby authorize representatives'of this city to enter upon the
above-mentioned property for inspection purposes. BOILER-COMP (Over 100,000 BTU)SEE FEE SCH. MECHANICAL
(We) agree to save, indemnify and keep harmless the City of MISC.- REFER TO ORD.
. Cupertino against liabilities,judgments, costs and expenses which CONST.TAX
- PERMIT ISSUANCE 10.00
may in any way accrue against said City in consequence of the
Kralit,ingof this ermit. ECH.CONT. LIC.NO. MECH.
44- pel/m 3_ TOTAL TOTAL
plimature f Applicant/ ontraclot l me '
OFFICE COPY